Cumberland_Well Abandonment_20230915 (4)

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WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Sebatian Britt a
7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or on water supply wells ONLY with the same
4567-C
constructionlabandonment,you canl- �submit one form.
NC Well Contractor Certification Number I
7b.Approximate volume of water remaining in well(s): 27 (gal.)
Blll's Well Drilling Co. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used HTH
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc.)if/mown 7d.Amount of disinfectant used 1 Ibs
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) oResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 300 Ibs bentonite chips
❑Aquifer Storage and Recovery []Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g•Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer 1.Pulled pump equipment
❑Geothermal(Heating(Cooling Return) ❑Other(explain under 7g)
k_ ,-,,y '7+ rp,,._, '� Measured depth of well and SWL
4.Date well(s)abandoned: 3-8-23 a""—C f:f �-••D Disinfected well
5a.Well location: SEP 1 K 2023 Filled to top with bentonite
T A Loving Company
info rir_-�4iori
Facility/Owner Name Facility IDiI,,1Np' f&b1P a.Certification:
7746 King Rd,'Fayetteville, NC 3-8-23
Physical Address,City,and Zip Signature of Certified Wel Contractor or Well Owner Date
Cumberland By signing this form, I hereby certify that the well(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.982659 -79.020463 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells Submit this form within 30 days of completion of well
6a.Well ID#:
abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 58 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
i.
10b.For Injection Wells: In addition to sending the form to the address in 10a
4 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
7 Division of Water Quality,,Underground Injection Control Program,
6d.Water level below ground surface: (ft.)
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Sunaly&Injection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) the address(es) above, also sulimit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
6f.Inner casing/tubing length(if known): (ft-) where abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013